Rectopexia laparoscópica con técnica de Orr-Loygue para el tratamiento del prolapso rectal / Laparoscopic Orr-Loygue rectopexy with mesh for the treatment of rectal prolapse

Introducción: Existen múltiples alternativas para el tratamiento quirúrgico del prolapso rectal mediante procedimientos de fijación, resección o combinados. Si bien el abordaje perineal evita el acceso a la cavidad peritoneal, se acompaña de una tasa de recidiva mayor en relación al abordaje abdominal. Descripción: Se presenta una paciente de 66 años, histerectomizada por vía laparotómica, con un prolapso rectal externo y reductible de 1 año de evolución, sin incontinencia fecal ni constipación. La endoscopia preoperatoria descartó patología colónica asociada. Abordaje laparoscópico en posición de Trendelenburg lateralizado a la derecha. Como es habitual en estos casos se observa la presencia de dolicosigma y fondo de saco de Douglas profundo y se evidencia también la cicatriz de la cesárea. El procedimiento comienza con la apertura peritoneal a nivel del promontorio y la movilización de la unión rectosigmoidea, identificando el uréter izquierdo. Se continua la disección circunferencial tras la apertura de la reflexión peritoneal hasta la altura de la cúpula vaginal. La rectopexia se realiza según la técnica de Orr-Loygue mediante la fijación de la malla por una parte a ambas caras laterales del recto y por otra al promontorio sacro con puntos de polipropileno 2-0, cuidando de no lesionar los vasos ilíacos y los uréteres. Finalmente se cierra la reflexión peritoneal con poliglactina para aislar las mallas protésicas del contenido visceral. La paciente tuvo una buena evolución postoperatoria, otorgándose el alta a las 48 h. Tras 8 meses de seguimiento se encuentra asintomática, con tránsito digestivo y continencia fecal sin alteraciones. Conclusión: El abordaje laparoscópico para el tratamiento del prolapso rectal es seguro y ofrece las ventajas de la cirugía mini-invasiva. La rectopexia con malla protésica es un procedimiento técnicamente desafiante, aunque con mejores resultados alejados. (AU)

Introduction: There are multiple alternatives for the surgical treatment of rectal prolapse through fixation, resection or combined procedures. Although the perineal approach avoids access to the peritoneal cavity, it is associated with a higher recurrence rate than the abdominal approach. Description: The video shows a 66-year-old female patient, hysterectomized by laparotomy, with a 1-year history of reduciblefull-thickness rectal prolapse, without fecal incontinence or constipation. Preoperative endoscopy ruled out associated colonic pathology. The laparoscopic approach is done with the patient placed in Trendelenburg and tilted to the right. As usual in these cases, the presence of dolichosigma and deep Douglas pouch is observed, as well as the cesarean section scar. The procedure begins with the peritoneal opening at the level of the promontory and the mobilization of the rectosigmoid junction, identifying the left ureter. Circumferential dissection is continued after opening the peritoneal reflection up to the level of the vaginal vault. Rectopexy is performed according to the Orr-Loygue technique by fixing the mesh to both lateral aspects of the rectum on one side and to the sacral promontory on the other side with 2-0 polypropylene interrupted sutures, taking care not to injure the iliac vessels and ureters. Finally, the peritoneum is closed with a running suture with polyglactin to isolate the prosthetic mesh from the visceral content. The patient had a good postoperative outcome and was discharged at 48 h. After 8 months of follow-up, she is asymptomatic and has normal colonic transit and fecal continence. Conclusion: the laparoscopic approach for the treatment of rectal prolapse is safe and offers the advantages of minimally invasive surgery. Prosthetic mesh rectopexy is a technically challenging procedure, although has better distant results. (AU)

Prolapso rectal completo / Complete Rectal Prolapse

Introducción: El prolapso rectal completo es la invaginación de las capas del recto a través del canal anal y su protrusión fuera de este. Su incidencia es de 2,5 por 100 000 habitantes con predominio en mujeres de edad avanzada. Es una afección de curso crónico y benigno, cuya presentación clínica y endoscópica es tan variable que puede confundirse con otras entidades como con el cáncer colorrectal. Objetivo: Presentar el caso de una paciente femenina, operada de prolapso rectal completo en la provincia de Cienfuegos. Presentación de caso: Se presenta una paciente femenina de 76 años de edad, blanca, de procedencia rural que acude a la consulta y refiere que lleva 12 días sin defecar. Además, presenta dolor, sangramiento rectal no activo y una masa que protruía a través de la región anal sugestiva al examen físico de un prolapso rectal completo. El tacto rectal confirma el diagnóstico. Se realiza reducción quirúrgica del prolapso por técnica de Delorme. Actualmente lleva 6 meses de operada con evolución favorable. Por lo poco frecuente de esta entidad se considera de interés científico su publicación. Conclusión: Esta entidad es poco común en el entorno médico, el gran cambio que causa en el nivel de vida de aquellos que la portan y sus complicaciones hace que requiera un tratamiento rápido y oportuno(AU)

Introduction: Complete rectal prolapse is the invagination of the rectal layers through the anal canal and its protrusion out of it. Its incidence is 2.5 per 100,000 inhabitants, predominantly in elderly women. It is a chronic and benign condition, whose clinical and endoscopic presentation is so variable that it can be confused with other entities, such as colorectal cancer. Objective: To present the case of a female patient who underwent surgery for complete rectal prolapse in the province of Cienfuegos. Case presentation: A 76-year-old female patient, white, from a rural area, came to the clinic and reported that she had not defecated for 12 days. In addition, she presents pain, nonactive rectal bleeding and a mass protruding through the anal region suggestive, on physical examination, of a complete rectal prolapse. Digital rectal examination confirmed the diagnosis. Surgical reduction of the prolapse was performed using the Delorme technique. She has undergone surgery for 6 months now, with favorable evolution. Due to the rarity of this entity, its publication is considered as scientifically interesting. Conclusion: This entity is uncommon in the medical environment. The great change that it causes in the living standards of those who carry it and its complications make it require a quick and timely treatment(AU)

AN EVALUATION OF CLINICAL OUTCOMES AFTER ABDOMINAL MESH RECTOPEXY & DELORME'S PROCEDURE FOR RECTAL PROLAPSE AT TERTIARY HEALTH CARE CENTER.

Background: Rectal prolapse is protrusion of rectum through anal canal, and proccidentia ~ complete prolapse is the term used when full thickness rectal wall prolapse . 30 patients presenting with Materials and methods: mass per rectum were evaluated & diagnosed clinically as having rectal prolapse were included in the study. The recurrence rate for the abdominal mesh Results: rectopexy is considered to be lower than Perineal Delorme's procedure. There was no recurrence in the rectopexy group. There was 1 recurrence (10%) in Delorme's group. .Better outcomes achieved when treatment individualized to Conclusion: each patient. Abdominal rectopexy for patients who can tolerate laparotomy & significant constipation. .Delorme's considered in young patients with short prolapse but with acceptable recurrence rate.

Prolapso rectal completo procedimiento de Delorme / Complete rectal prolapse Delorme procedure / Procedimento completo de prolapso retal Delorme

Introducción: el prolapso rectal es una invaginación del recto que produce su exteriorización a través del ano. Se denomina completo cuando está constituido por todo el espesor de la pared rectal. En su incidencia están vinculados factores como el sexo femenino, los pacientes añosos y el parto. Etiopatogenia: es multifactorial, se plantean varias teorías. Entre ellas, un fondo de saco peritoneal recto vaginal o recto vesical anormalmente profundo, la falta de fijación normal del recto a su lecho, la consecuencia de una invaginación idiopática de la parte superior del recto y un estado de relajación y atonía de la musculatura del suelo de la pelvis y del canal anal. Caso Clínico: mujer, 64 años. Prolapso rectal completo por debilidad de la musculatura del piso pélvico y canal anal. Se plantean la valoración diagnóstica y exámenes paraclínicos preoperatorios. Se describe el procedimiento de Delorme como solución técnica a su prolapso rectal. Se destaca que la paciente evolucionó favorablemente. Conclusiones: el objetivo del tratamiento es solucionar el prolapso y restaurar la función anorrectal sin provocar efectos nocivos. El prolapso que presenta esta paciente es multifactorial e incluye el conjunto de las siguientes anomalías, afecta a las mujeres de edad avanzada y multíparas, está exteriorizado permanentemente y forma parte de una enfermedad degenerativa difusa del periné. El mismo fue solucionado según el procedimiento de Delorme. La evolución de la paciente fue satisfactoria, no se objetivaron complicaciones ni recidiva en el post operatorio precoz o alejado.

Introduction: rectal prolapse is an invagination of the rectum that produces its exteriorization through the anus. It is called complete when it is constituted by the whole thickness of the rectal wall. Factors such as female sex, elderly patients and childbirth are linked to its incidence. Etiopathogenesis: it is multifactorial, and several theories have been put forward. Among them, an abnormally deep peritoneal rectal vaginal or rectal vesical fornix, the lack of normal fixation of the rectum to its bed, the consequence of an idiopathic invagination of the upper part of the rectum and a state of relaxation and atony of the muscles of the pelvic floor and the anal canal. Case report: female, 64 years old. Complete rectal prolapse due to weakness of the pelvic floor muscles and anal canal. The diagnostic evaluation and preoperative paraclinical examinations are presented. The Delorme procedure is described as a technical solution to her rectal prolapse. It is emphasized that the patient evolved favorably. Conclusions: The goal of treatment is to resolve the prolapse and restore anorectal function without causing harmful effects. The prolapse presented by this patient is multifactorial and includes all of the following anomalies, affects elderly and multiparous women, is permanently externalized and is part of a diffuse degenerative disease of the perineum. It was solved according to the Delorme procedure. The patient's evolution was satisfactory, no complications or recurrence were observed in the early or distant postoperative period.

Introdução: O prolapso retal é uma invaginação do reto que resulta em sua externalização através do ânus. É chamado completo quando consiste de toda a espessura da parede retal. Fatores como sexo feminino, pacientes mais velhos e parto estão ligados a sua incidência. Aetiopatogênese: é multifatorial, e várias teorias foram apresentadas. Estes incluem um fórnix peritoneal rectovaginal ou retal vesical anormalmente profundo, a falta de fixação normal do reto em seu leito, a conseqüência da invaginação idiopática da parte superior do reto e um estado de relaxamento e atonia dos músculos do assoalho pélvico e do canal anal. Relato de caso: mulher, 64 anos de idade. Prolapso retal completo devido à fraqueza dos músculos do assoalho pélvico e do canal anal. São apresentados a avaliação diagnóstica e os exames paraclínicos pré-operatórios. O procedimento Delorme é descrito como uma solução técnica para seu prolapso retal. Observa-se que o paciente evoluiu favoravelmente. Conclusões: O objetivo do tratamento é resolver o prolapso e restaurar a função anorretal sem causar efeitos nocivos. O prolapso apresentado por esta paciente é multifatorial e inclui todas as seguintes anomalias, afeta mulheres idosas e multíparas, é externalizado permanentemente e faz parte de uma doença degenerativa difusa do períneo. Foi tratado de acordo com o procedimento Delorme. A evolução do paciente foi satisfatória, não foram observadas complicações ou recidivas no período pós-operatório precoce ou distante.

Is it possible to optimize stapled hemorrhoidopexy outcomes by enlarging operative criteria indications? results of a tailored procedure with associated resection in a comparative personal series / é possível otimizar os resultados da hemorroidopexia grampeada pela ampliação dos critérios de indicação operatória? resultados de um procedimento personalizado com ressecção associada em uma série comparativa pessoal

ABSTRACT BACKGROUND: Since its introduction, stapled hemorrhoidopexy has been increasingly indicated in the management of hemorrhoidal disease. AIM: Our primary end point was to evaluate the incidence of recurrent disease requiring another surgical intervention. On a secondary analysis, we also compared pain, complications, and patient's satisfaction after a tailored surgery. METHODS: We retrospectively reviewed 196 patients (103 males and 93 females) with a median age of 47.9 years (range, 17-78) who were undergoing stapled hemorrhoidopexy alone (STG; n=65) or combined surgery (CSG; n=131, stapled hemorrhoidopexy associated with resection). RESULTS: Complications were detected in 11 (5.6%) patients (4.6% for STG vs. 6.1% for CSG; p=0.95). At the same time, symptoms recurrence (13.8% vs. 8.4%; p=034), reoperation rate for complications (3.1% vs. 3.0%; p=1.0), and reoperation rate for recurrence (6.1% vs. 4.6%; p=1.0) were not different among groups. Grade IV patients were more commonly managed with simultaneous stapling and resection (63% vs. 49.5%), but none of them presented symptoms recurrence nor need reoperation due to recurrence. Median pain score during the first week was higher in CSG patients (0.8 vs. 1.7). After a follow-up of 24.9 months, satisfaction scores were similar (8.6; p=0.8). CONCLUSION: Recurrent symptoms were observed in 10% of patients, requiring surgery in approximately half of them. Even though the association of techniques may raise pain scores, a tailored approach based on amplified indication criteria and combined techniques seems to be an effective and safe alternative, with decreased relapse rates in patients suffering from more advanced hemorrhoidal disease. Satisfaction scores after hemorrhoidopexy are high.

RESUMO RACIONAL: Desde sua introdução, a hemorroidopexia por grampeamento tem sido cada vez mais indicada no manuseio da doença hemorroidária. OBJETIVOS: Nosso objetivo primário foi avaliar a incidência de doença recidivada que requeira tratamento cirúrgico. Numa análise secundária, também comparamos dor, complicações e satisfação do paciente após uma operação ajustada a cada caso. MÉTODOS: Foram revistos retrospectivamente 196 pacientes (103 homens e 93 mulheres) com idade média de 47,9 anos (17-78) submetidos a hemorroidopexia mecânica isoladamente (STG; n=65) ou cirurgia combinada (CSG; n=131, hemorroidopexia por grampeamento com ressecção). RESULTADOS: Complicações foram detectadas 11 (5,6%) pacientes (4,6% para STG vs. 6,1% para CSG; p=0,95). Ao mesmo tempo, recidiva de sintomas (13,8% vs. 8,4%; p=034), reoperações por complicações (3,1% vs. 3,0%; p=1,0) ou por recidiva (6,1 vs. 4,6%; p=1,0) não foram diferentes entre os dois grupos. Pacientes com grau IV foram mais comumente manuseados com grampeamento e ressecção simultâneos (63% vs. 49,5%), mas nenhum deles apresentou recidiva ou necessitou reoperação. O escore médio de dor na primeira semana foi maior no grupo CSG (0,8 vs. 1,7). Após seguimento de 24,9 meses, os índices de satisfação foram similares (8,6; p=0,8). CONCLUSÕES: Sintomas de recidiva foram observados em 10%, requerendo cirurgia em aproximadamente metade dos doentes. Embora a associação de técnicas aumente os escores de dor, um procedimento sob medida baseado em critérios ampliados de indicação e técnicas combinadas parece ser uma alternativa efetiva e segura, com menor recidiva em pacientes portadores de doença hemorroidária mais avançada. Os escores de satisfação após hemorroidopexia são altos.

Integral theory-guided laparoscopic pelvic floor/ligament repair in the treatment of women's internal rectal prolapse / 中华普通外科杂志

Objective:To compare the clinical efficacy of laparoscopic integral pelvic floor/ligament repair (IPFLR) combined with a procedure for prolapse and hemorrhoids (PPH) and that laparoscopic IPFLR alone in the treatment of internal rectal prolapse (IRP) in women.Methods:Patients were divided into groups A in which 63 patients undergoing laparoscopic IPFLR alone, and group B of 67 patients reciving laparoscopic IPFLR combined with PPH. The degree of internal rectal prolapse (DIRP), Wexner constipation scale (WCS) score, Wexner incontinence scale (WIS) score, and Gastrointestinal Quality of Life Index (GIQLI) score were compared between these two groups and in each group those before surgery and 6 months, 2 years, and 5 years after surgery.Results:The number of bowel movements , DIRP, WCS score, WIS score, and GIQLI score before surgery were not significantly different between the two groups (all P>0.05). The DIRP, WCS score, WIS score, and GIQLI score in each group 6 months, 2 years, and 5 years after surgery in both two groups were significantly better than those before surgery (all P<0.001). The DIRP, WCS score, WIS score, and GIQLI score in group B were significantly better than those in group A at 6 months, 2 years, and 5 years after surgery (all P<0.05) except DIRP at 2 years after surgery (all P<0.05). There was a significant difference in the recurrence rate of IRP between the two groups when evaluated at 5 years after surgery ( P=0.001). Conclusions:Integral theory-guided laparoscopic IPFLR combined with PPH has a higher cure rate and a better clinical efficacy than laparoscopic IPFLR alone.

Clinical analysis of Delorme procedure for full-thickness rectal prolapse / 中国医师进修杂志

Objective:To evaluate the safety and efficacy of Delorme procedure for adults with full-thickness rectal prolapse.Methods:Clinical data of 17 adult patients suffering from full-thickness rectal prolapse undergoing Delorme procedure from June 2014 to May 2018 in Hangzhou Third Hospital were retrospectively analyzed. Patient characteristics, operative data, postoperative complications, recurrence of rectal prolapse, continence state and constipation state were evaluated.Results:Eleven patients were female, 6 patients were male with a mean age of (68 ± 9) years. Operations were successfully performed in these 17 cases. The operation time was (88 ± 16) minutes. The estimated blood loss during operation was (23 ± 9) ml. The postoperative time of hospital stay was (8 ± 1) d. Two complications in two patients were observed. There was no treatment related death. One recurrent case was observed during (16 ± 2) months follow-up. The preoperative and postoperative mean constipation score of five patients with fecal constipation were (23 ± 2) and (11 ± 3) respectively ( t = 9.51, P<0.01). The mean fecal incontinence score of six patients with fecal incontinence, before and after Delorme procedure, were (14 ± 2) and (6 ± 2) respectively ( t = 9.09, P<0.01). Conclusions:The Delorme procedure for adults with full-thickness rectal prolapse is a safe and effective surgery with less complications and low recurrence rate. The Delorme procedure may be one of the preferred option of perineal approach for adults with full-thickness rectal prolapse, but the long-term outcome of Delormer procedure and its effect on postoperative anal function need to be further studied.

Pelvic floor holistic theory guided complete rectal prolapse manegement / 中华普通外科杂志

Objective:To evaluate pelvic floor holistic theory used in the treatment of complete rectal prolapse (CRP).Methods:Forty-two CRP patients at No. 989 Hospital between Oct 2015 and Jun 2019 were divided into group A ( n=23) treated by laparoscopic rectopexy associated with the procedure for PPH, and group B ( n=19), by Altemeier precedure. The degree of rectal prolapse, Wexner fecal incontinence score and Wexner constipation score were evaluated before operation and at the 6th,12th and 24th months after operation Results:The operation time of the two groups were (53±6) and (90±9) min; intraoperative blood loss was (14±5) and (80±19) ml; the hospital stay was (8.9±1.7) and (13.5±2.1)d, all P<0.05. There was no significant difference in postoperative recurrence between the two groups ( P>0.05). The degree of rectal prolapse in group A and B were (9.5±1.7) and (8.7±1.5)cm; the 6 th, 12 th and 24 th months after operation were [(-1.0±1.6), (-0.2±1.8)cm; (-1.0±1.3), (-0.3±1.5)cm; (-0.8±1.2), (-0.5±1.6)cm], all P<0.05. The preoperative constipation in group A and group B was (6.4±1.7) and (6.4±1.5) respectively; the 6 th, 12 th and 24 th months after operation were [(2.8±1.0) vs. (3.0±1.3); (2.6±1.1) vs. (2.8±1.3); (2.0±0.9) vs. (2.3±1.1)], all P<0.05. The preoperative fecal incontinence score of group A and group B were (7.6±1.7) vs. (7.1±1.5); the 6 th, 12 th and 24 th months after operation were [(3.7±1.7) vs. (3.4±1.2); (3.5±1.8) vs. (3.1±1.1); (3.4±1.9) vs. (2.6±1.3)], all P<0.05. Conclusion:Pelvic floor holistic theory help improve the treatment of complete rectal prolapsed.

Homeopathic treatment of rectal prolapse in a kitten: a case report

Rectal prolapse be either partial or incomplete in nature and is defined as double layer evagination of the rectum through the anal canal. The common associated causations which can be seen in kittens are severe endoparasitism, enteritis, and associated tenesmus (Fossum, 2002). Rectal prolapse is the one of the most encountered surgical conditions involving the rectum in all domestic animal species (Tyagi and Singh, 1993). Surgical intervention is the most common treatment methodology adopted but however, in cases where surgery is not indicated, required, not opted by the owner, becomes a challenge to treat. Therefore, finding alternative therapies for clinical management is the need of hour. The objective of this study is to report successful management of rectal prolapse in a 5-month-old kitten having 4 episodes of prolapse in five days. The homeopathic medicines used in this case were Sepia 200C and Ruta g. 200C. The patient revealed a favourable response by 2nd day of the treatment and complete healing was observed on 7th day. This therapeutic protocol used was conclusive and it re-established the normal intake of food and energy level. Hence, homeopathic treatment can be considered as an alternative therapy for clinical management of rectal prolapse in a Felines and Canines.

Prolapso rectal encarcelado resuelto por procedimiento de Altemeier Reporte de caso / Incarcerated rectal prolapse resolved by the Altemeier procedure. About a case

RESUMEN El prolapso rectal tiene una incidencia estimada en la población general de 2.5/100000, con predominio del sexo femenino y en pacientes mayores de 50 años. La etiología es multifactorial, el prolapso rectal encarcelado es raro y constituye una urgencia quirúrgica. El procedimiento de Altemeier es una alternativa válida en estos casos por su baja morbilidad. Se describe a continuación un caso clínico de un paciente sometido de urgencias a rectosigmoidectomía de Altemeier, con buena respuesta en el posoperatorio y sin complicaciones post quirúrgicas.

ABSTRACT Rectal prolapse has an estimated incidence in the general population of 2.5 / 100,000, with a predominance in women and in patients over 50 years of age. The etiology is multifactorial, incarcerated rectal prolapse is rare and constitutes a surgical emergency. The Altemeier procedure is a valid alternative in these cases due to its low morbidity. A clinical case of a patient who underwent an Altemeier rectosigmoidectomy is described below, with a good response in the postoperative period and without postoperative complications

The colostomy complications in anorectal malformation: a retrospective study

Background: A colostomy is a surgical approach that creates an opening for the colon, or/and large intestine through the abdomen. Anorectal malformations are a group of abnormalities of the rectum and anus that are present at birth. Objective: To analyze the common complications of colostomy in anorectal formations. Methods: This was a retrospective study conducted on 50 temporary colostomies performed in children at the Surgical Department of the Abu Ghraib General Hospital in the period from January 2018 to January 2020. Information was collected regarding the patients' age, sex, body weight, associated anomalies, colostomy types and sites, and the indications and complications of colostomies. Results: A total of 44 (88%) cases were reported in the children's 1st month of life. The ratio of male to female was 1:1. Pelvic colostomy was performed in 48 (96%) patients, as 40 (80%) children underwent a loop-type, and 8 (16%) patients underwent doublebarrel colostomy. Transverse colostomy was performed on two patients. Prolapse occurred in 50% of the patients, and skin excoriations occurred in 22% . A total of 10% of the children developed sepsis. Bleeding was seen in 4% of the children after colostomy performance. Stenosis presented in 6% of the children, and this was corrected by repeated dilatation and re-fashioning. Obstruction of intestines was observed in one patient. The retraction developed in 6% of patients. Conclusions: Imperforate anus was themost common indication for stoma formation in the pediatric age group. Loop colostomy was the most common type used, and it had the highest rate of complications. Prolapses and skin excoriation were the most common complications found. (AU)

Outcome of Fecal Incontinence in Patients with Rectal Prolapse Undergoing the Altemeier Procedure with or without Posterior Levatorplasty / Desfecho de incontinência fecal em pacientes com prolapso retal submetidos ao procedimento de Altermeier com ou sem levatorplastia posterior

Abstract Objective To compare the fecal incontinence status of patients submitted to theAltemeier procedure with or without posterior levatorplasty. Materials and Methods Medical records of the patients who underwent the Altemeier procedure at Shahid Faghihi Hospital (in Shiraz, Iran) from 2014 to 2018 were retrospectively studied. Patients older than 17 years of age who underwent the Altemeier procedure due to complete rectal prolapse were considered. In some cases, the operation was performed with posterior levatorplasty. Rectal prolapse due to collagen or connective tissue disorders, anal/sacral anomalies, immunodeficiency, history of rectal surgery, and pelvic radiotherapy were the exclusion criteria of the present study. In addition to the demographics (including age, gender, and body mass index), the fecal incontinence status of each case was determined through theWexner scale preoperatively and 12 months after the surgery. The incontinence scores were then compared against the baseline values of the two groups of patients: those with and those without posterior levatorplasty. The statistical analysis was performed using the Statistical Package for the Social Sciences (SPSS, IBM Corp., Armonk, NY, US), software, version 21. Results In total, 53 patients (17 men and 36 women) with a mean age of 55.23 ± 18.24 years were analyzed. The comparison of the pre- and postoperative scores on theWexner scale between the two groups revealed no statistically significant difference (p >0.05). Conclusion Posterior levatorplasty during the Altemeier procedure did not result in significant improvement of the fecal incontinence outcome of the patients.

Resumo Objetivo Comparar o status de incontinência fecal de pacientes após o procedimento de Altemeier com e sem levatorplastia posterior. Materiais e métodos Os prontuários médicos dos pacientes submetidos ao procedimento de Altemeier no Shahid Faghihi Hospital (em Shiraz, Irã) entre 2014 e 2018 foram avaliados retrospectivamente. Pacientes com idade superior a 17 anos submetidos ao procedimento de Altemeier devido a prolapso retal completo foram considerados. Em alguns casos, a operação foi realizada com levatorplastia posterior. Prolapso retal devido a distúrbios de colágeno ou do tecido conjuntivo, anomalias anais/sacrais, imunodeficiência, histórico de cirurgia retal, e radioterapia pélvica foram os critérios de exclusão deste estudo. Além dos dados demográficos (incluindo idade, sexo, e índice de massa corporal), o status da incontinência fecal de cada caso foi determinado por meio da escala de Wexner antes e doze meses após a cirurgia. Então, as pontuações de incontinência foram comparadas aos valores de referência dos dois grupos de pacientes: com e sem levatorplastia posterior. A análise estatística foi feita usandose o programa Statistical Package for the Social Sciences (SPSS, IBM Corp., Armonk, NY, EUA), versão 21. Resultados No total, 53 pacientes (17 homens e 36 mulheres) com idade média de 55.23 ± 18.24 anos foramavaliados. A comparação entre os grupos das pontuações na escala de Werner no pré e pós-operatório não revelou diferença estatisticamente significativa (p>0.05). Conclusão Levatorplastia superior durante o procedimento de Altemeier não resultou em melhora significativa do desfecho da incontinência fecal dos pacientes.

Assessment of incidence of recurrence and constipation in patients of rectal prolapse undergoing rectal mobilization only with division of lateral stalks

Background: Rectal prolapse is a pelvic floor disorder that can occur in men and women of all ages. It results in pain, bleeding per rectum, seepage, diarrhoea or constipation and a disabled quality of life. With the advent of twentieth century, perineal operative procedures have become more common. Perineal procedures though have lower morbidities but have higher recurrence rate and high incidence of post-operative constipation. Novel abdominal approaches to rectal prolapse repair also became common during the first half of this century. Numerous types of surgical procedures have been attempted. Most techniques developed till now have some advantages and some short comings. CT Speakman and Pollen et al have shown in their studies   that division of lateral ligaments caused new onset constipation and they attributed this effect to denervation of rectum. As the issue of recurrence and post-operative constipation remained unsettled.Methods: This was an observational study to assess the incidence of recurrence and post-operative constipation in patients of rectal prolapse. In well selected patients, we performed complete rectal mobilization with division   of lateral ligaments. We assessed the patients on the basis of Clevland clinical constipation scoring system.Results: Out of 25 patients, 4 patients developed constipation, 2 had mild and 2 had moderate constipation and 2 patients had recurrence. Patients were kept under six monthly follow-up till a period of eighteen months.Conclusions: Only rectal mobilization with division of lateral ligaments can be a good surgical option in patients of rectal prolapse not having severe constipation.

Perineal Rectosigmoidectomy Associated with Low Colorectal Anastomosis for Complete Rectal Prolapse Correction – Altemeier’s Procedure

Introduction: Rectal prolapse constitutes in rectal protrusion through anal orifice. It’s more frequent in elderly women and the correction is exclusively surgical and fundamental, given the condition’s social relevance. We intend to describe a perineal rectosigmoidectomy (Altemeier) for correction of prolapse in multi-morbidity elder patient. Case Report: Female patient, 78 years old, evaluated by proctology ward of CHSBC. She Came in with complaint of anal region bulge for past 2 years. Proctological examination showed 15 cm rectal procidentia Rectal prolapse’s diagnosis came from colonoscopy. A perineal rectosigmoidectomy associated with colorectal anastomosis was done (Altemeier’s Procedure). There was appropriate postoperative evolution, discharge with good wound healing and ambulatorial follow up with good general healing.Discussion: Rectal prolapse is a result of anatomical alterations due to factors such as age and multiparity. Clinical presentation: abdominal discomfort, constipation, feces and gases release. Itleads to life quality loss, thus surgical interventions become essential. Corrective surgeries seek to give back fecal continence. Currently, procedures branch out into abdominal and perineal. Altemeier consists in complete rectal removal via perineum. It’s appropriate for high surgical risk elders, since it has the lowest complications rate

Management of rectal prolapse (Guda Bhramsa) through Kshara Karma (chemical cauterisation): a case study / Manejo do prolapso retal (Guda Bhramsa) usando Kshara Karma(cauterização química): um estudo de caso

Abstract Rectal Prolapse is a condition where the rectum protrudes beyond the anus. The explanation of this condition can be traced back to ancient Ayurveda text like Susruta Samhita, Ebers Pappyrus of 1500 B.C., etc. The exact cause of rectal prolapse is unclear but it is predominant on female gender and on people having constipation, previous anorectal surgeries etc. Both partial and complete varieties of rectal prolapse are extremely debilitating because of the discomfort of the prolapsing mass and variety of symptoms like rectal bleed, intermittent constipation or fecal incontinence. Although, diverse modalities of surgical management of rectal prolapse are present, no single optimal procedure is proved and the choice of operation is determined by the patient's age, sex, degree of incontinence, operative risk, as well as by the surgeon's experience. In Ayurveda, Guda Bhramsa (Rectal prolapse) is explained by Acharya Susruta under Kshudra Rogas (chapter of minor diseases) and has elaborated it's conservative management very beautifully. In this case, a female with partial rectal prolapse was treated with Kshara application and managed without complications. So, Kshara application can be a safe and effective alternative for the management of rectal prolapse.

Resumo O prolapso retal é uma condição em que o reto se projeta para além do ânus. A explicação desta condição foi relatada em antigos textos Ayurveda como Susruta Samhita e Ebers Pappyrus, datados de 1500 aC. A causa exata do prolapso retal não é clara, mas essa condição é predominante no sexo feminino e nas pessoas com constipação e histórico de cirurgias anorretais anteriores. Tanto o prolapso retal parcial quanto total são extremamente debilitantes devido ao desconforto da massa prolapsante e da variedade de sintomas como sangramento retal, constipação intermitente ou incontinência fecal. Embora diversas modalidades de tratamento cirúrgico para corrigir o prolapso retal tenham sido relatadas na literatura, nenhum procedimento é consensual; a escolha da operação é determinada pela idade, sexo, grau de incontinência, risco operatório e experiência do cirurgião. Na Ayurveda, Guda Bhramsa (prolapso retal) é explicado por Acharya Susruta no Kshudra Rogas (capítulo de doenças menores) e seu manejo conservador é descrito de forma bastante completa. No presente caso, uma paciente do sexo feminino com prolapso retal parcial foi tratada com aplicação de Kshara e administrada sem complicações. Assim, a aplicação de Kshara pode ser uma alternativa segura e eficaz para o manejo do prolapso retal.

Laparoscopic Rectopexy – A New Management for Rectal Prolapse at the Georgetown Public Hospital Corporation

Introduction:Rectal prolapse is a debilitating and unpleasant condition adversely affecting the quality of life. It is a distal displacement of the rectum through the pelvic diaphragm that produces pressure symptoms on other pelvic organs causing fecal incontinence, obstructive defecation, or even strangulation. Different perineal and abdominal approaches have been described for surgical correction of rectal prolapse. Laparoscopic Rectopexy has been proven to be an effective treatment for rectal prolapse. Objective:LPR has recently been practiced as a method of treatment for rectal prolapse at GPHC. This study aims to assess the clinical and functional outcomes of the patients who underwent Laparoscopic Rectopexy in the effort to highlight this practice in Guyana and the Caribbean. Design /Method:The study design includes a retrospective review and prospective follow-up of a series of 4 patients who underwent LPR at GPHC for rectal prolapse. Pre-operative, intra-operative and post-operative factors surrounding the procedure were recorded and analyzed.Results:All patients were males of 29-52 years of age. One (1) Patient was a smoker and One (1) used alcohol. Two (2) patients had a previous perineal approach for rectal prolapse that recurred. No comorbidities were recorded. All patients had complete rectal procidentia. Laparoscopic Ventral Mesh Rectopexy was done for each patient. None of the cases were converted. All patients were fully ambulant by postoperative day one and all were discharged by postoperative day three. No short-term recurrence was recorded for three patients; the fourth patient did not complete the six months postoperative period. Conclusion: Laparoscopic Rectopexy was successfully pioneered at GPHC as a method of management for rectal prolapse with good outcomes

Prospective Study on Effect of Submucosal Alcohol Injection in Cases of Rectal Prolapse in Infants and Children

Purpose: The purpose of the study was to study the impact of sclerosing agent in cases of rectal prolapse in infants and children.Materials and Methods: A total of 200 cases of diagnosed rectal prolapse in infants and children attending a tertiary care ofWest Bengal were included in the study for the effect of submucosal injection of alcohol from a period of August 2016 to July2018. 1.5–2 ml of alcohol was linearly injected in three sites (two laterals and one posterior).Results: All 200 cases were followed at 3 months interval for a period of 2 years. One hundred and twenty-one patients (60.5%)had a duration of prolapse for 3–6 months. Forty-six patients (23.0%) had prolapse for more than 8 months and 33 (16.5%)patients had prolapse for more than 1 year. One hundred and ninety-one (90.5%) patients responded to a single injection. Fivepatients (2.5%) required the second injection. Four (2%) patients with age more than 10 years did not respond to the treatment.Twenty-five patients had fecal soiling for a period of 10–12 days. No infectious complication and no recurrence were observed.Conclusion: 2–5 ml of ethyl alcohol (96%) is effective for the treatment of rectal prolapse. The duration of rectal prolapsehad no deleterious effect on treatment; however, patients with age more than 10 years did not respond to sclerosing agent,probably due to different etiology.

Prolapso rectal incarcerado secundario a adenoma velloso gigante / Incarcerated rectal prolapse due to a giant villous adenoma

Los adenomas vellosos pueden manifestarse con sangrado, diarrea, alteraciones hidroelectrolíticas (síndrome Mackittrick-Weelock), obstrucción intestinal, y, muy infrecuentemente, condicionar un prolapso rectal. El prolapso rectal es la protrusión de la pared completa del recto a través del canal anal, su presentación como prolapso rectal incarcerado es poco habitual. Cuando la reducción manual no es posible, la rectosigmoidectomía vía perineal o procedimiento de Altemeier es una buena opción quirúrgica; como alternativa puede realizarse una resección transanal del pólipo y la posterior reducción manual del prolapso rectal. Referiremos el caso de una mujer que acude al Servicio de urgencias presentando un prolapso rectal incarcerado con una masa ulcerada, friable, de 10 × 8 × 5 cm compatible con un pólipo velloso en la cara posterior del recto. Ante la imposibilidad de reducirlo se decide una resección transanal del pólipo con posterior reducción manual del prolapso rectal. Este caso es de interés por la infrecuente asociación entre un prolapso rectal incarcerado y un pólipo velloso gigante, con solo 4 casos comunicados en la literatura.

Villous adenomas may present with bleeding, diarrhea, electrolyte imbalance (Mackittrick-Weelock syndrome), obstruction, being a very rare cause of rectal prolapse. Rectal prolapse is a full thickness protrusion of the rectum through the anal canal and its presentation as an incarcerated rectal prolapse is very infrequent. If manual reduction is deemed impossible, perineal recto-sigmoidectomy, or Altemeier's procedure, is one of the best surgical options, as an alternative transanal excision of the polyp could be performed with subsequent manual reduction of the rectal prolapse. We report the case of a female patient, admitted to the emergency room presenting an incarcerated rectal prolapse with a friable ulcerated mass of 10 × 8 × 5 cm, compatible with a villous polyp in the back side of the rectum. Since manual reduction was considered not feasible, surgery was decided and a transanal excision of the polyp was performed, following a successful manual reduction of the rectal prolapse. This case is of particular interest for its unusual association of incarcerated rectal prolapse due to a giant villous adenoma, having only 4 cases been reported in the literature.

Anal position index; can it predict pelvic organ disorders in adults? / O índice de posição anal pode prever doenças de órgãos pélvicos em adultos?

ABSTRACT Introduction: Anal position index is calculated with a simple formula, which is used to determine the exact position of anus in perineum. This index is currently used only in neonates and infants. Anteriorly displacement of anus is a common cause of chronic constipation. Here we assessed the association between anal position index with patients' characteristics, chronic constipation, rectum prolapse uterine prolapse, and number of delivery. Material and methods: This was a cross-sectional study performed in 2018 on 63 adult admitted to colorectal surgery clinic. Anus-forchuette, coccyx-forchuette and coccyx-scrotum and anal-scrotum were measure by a simple meter tape. Statistical Package for the Social Sciences (SPSS for Windows, ver. 18) was used for data analysis. Independent Student's t-test, correlation coefficient and ANOVA were used. Results: Sixty-three patients within age range of 22-75 years old were recruited. 48 were male (76.2%) and 15 females (23.8%). Twenty-nine (46%) had chronic constipation. The mean ± SD of the index with confidence interval of 95% was 0.5325 ± 0.11861 in males and 0.4510 ± 0.16803 in females. Also the mean of the index was 0.4616 ± 0.14007 in patients with chronic constipation and 0.5570 ± 0.11559 in patients without constipation. Discussion: Anal position index can be a prognostic factor to predict chronic constipation and pelvic floor anatomy disturbance in adults as well as pediatrics.

RESUMO Introdução: O índice de posição anal é calculado com uma fórmula simples, usada para determinar a posição exata do ânus no períneo. Atualmente, esse índice é usado apenas em neonatos e bebês. O deslocamento anterior do ânus é uma causa comum de constipação crônica. No presente estudo, avaliou-se a associação entre o índice de posição anal e as características dos pacientes, constipação crônica, prolapso uterino, prolapso do reto e número de partos. Material e Métodos: Este estudo transversal, realizado em 2018, incluiu 63 adultos admitidos na clínica de cirurgia colorretal. As distâncias ânus-frênulo dos lábios, cóccix-frênulo, cóccix-escroto e ânus-escroto foram medidas com uma fita métrica simples. O SPSS for Windows (v. 18) foi usado para análise dos dados. O teste t de Student para variáveis independentes, o coeficiente de correlação e o teste ANOVA foram usados. Resultados: Sessenta e três pacientes com idade entre 22 a 75 anos foram recrutados; 48 eram do sexo masculino (76,2%) e 15 do sexo feminino (23,8%). Destes, 29 (46%) apresentavam constipação crônica. A média ± DP do índice, com intervalo de confiança de 95%, foi de 0,5325 ± 0,11861 no sexo masculino e 0,4510 ± 0,16803 no sexo feminino. Além disso, a média do índice foi de 0,4616 ± 0,14007 em pacientes com constipação crônica e 0,5570 ± 0,11559 em pacientes sem constipação. Discussão: O índice de posição anal pode ser um fator prognóstico para predizer constipação crônica e alterações da anatomia do assoalho pélvico em pacientes adultos e pediátricos.

Transperineal ultrasound in evaluation of the degree of rectal prolapse in females with rectal prolapse disease / 中国医学影像技术

Objective: To investigate the value of transperineal ultrasound in evaluation of the degree of rectal prolapse in females with rectal prolapse disease. Methods: Totally 26 women with rectal prolapse disease were divided into internal rectal prolapse (IRP) group (n=18) or external rectal prolapse (ERP) group (n=8) according to whether rectal prolapsed outside the anus or not. Meanwhile, 20 healthy women were selected as control group. All subjects underwent transperineal ultrasound. The position of rectum ampulla, rectal motility, the size of the pelvic diaphragm hiatus and anorectal angulation were measured at rest state and during straining and compared among 3 groups. Results: Compared with those at resting state, the size of the pelvic diaphragm hiatus increased and the position of rectal ampulla decreased in 3 groups during straining (all P0.05). Rectal motility in IRP group and ERP group were higher than that in control group (both P0.05). Conclusion: Transperineal ultrasound can be used to evaluate the degree of rectal prolapse in females with rectal prolapse disease.